Built Bigger, Tougher, Better: Today's Beds & Support Surfaces Beef Up to Meet the Unique Needs of Bariatric Clients

Ask Ron Resnick, a former bariatric client and president of Blue Chip Medical Products, Suffern, N.Y., to describe the most important feature of bariatric beds and support surfaces and the first thing he talks about is comfort.

"Just because you're heavy," says Resnick, "doesn't mean you shouldn't be comfortable."

Standard beds simply aren't constructed to support the added weight of a bariatric client comfortably, as many buckle in the center. And comfort is essential because a hard surface means an increased risk for pressure sores. Aside from some extra support, bariatric beds and support surfaces must incorporate design components that meet the varied needs of bariatric clients. To create the right environment, an HME dealer must consider the whole picture.

"You have a balance here: quality, longevity and then clinical outcome," says Resnick.

According to the National Institutes of Health, 55 percent of adults in the United States are now overweight or obese. As obesity rates continue to reach epidemic proportions, manufacturers are ramping up to supply equipment to meet individualized needs in the bariatric marketplace.

It's not just making it bigger. It's got to be tougher, but at the same time it has to have clinical efficacy. —Ron Resnick, Blue Chip Medical Products, referring to bariatric beds.

"It's not just making it bigger," says Resnick of bariatric beds. "It's got to be tougher, but at the same time it has to have clinical efficacy."

Resnick warns HMEs that just because a mattress fits an oversized bed doesn't mean it's bariatric. "Don't be fooled by the cover. Don't be fooled by the size," he says.

But if size isn't the only factor, what exactly does a bariatric client need in a bed or support surface?

The Truth About Bariatrics

The modern bariatric client weighs anywhere from 350 lbs. to 1,000 lbs. — and possibly more.

With added weight comes additional medical conditions. Some of the most common co-morbidities include hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and endometrial, breast, prostate and colon cancers, according to the Centers for Medicare & Medicaid Services (CMS).

Translation: One size does not fit all in the bariatric group. These conditions might mean the choice between a low air loss mattress and a lateral rotating mattress.

For example, diabetes, which is common among bariatric clients, reduces sensation and thereby increases the risk of wounds. "Additionally, there's a problem with wound healing," says Dr. Mary Vernon, a bariatric physician in Lawrence, Kan., and president of the American Society of Bariatric Physicians, "which is much poorer in diabetics because having your blood sugar elevated alters how your body will really handle chasing after the infectious agents that are present."

As a result, a bariatric client with diabetes will typically require a support surface that relieves pressure.

Weight also influences the size bed or type of support surface required. "The bed has to be rated appropriately to the client's weight class," explains Dr. Kevin Huffman, president of American Bariatric Consultants.

In addition, Dr. Vernon says, "A 200-pounder with a leg amputation is a different scenario than a 400-pounder with an abdominal wound." Therefore the caregiving team will need to "pick the surface that best suits the patient."

A bariatric patient, someone that weighs 500 or 600 lbs., say, will lose or gain up to 50 lbs. of weight in a single day. —Mike Irvine, Invacare.

Another consideration, says Mike Irvine, Invacare's product manager for beds & therapeutic support surfaces, Elyria, Ohio, is the amount of weight fluctuation. "A bariatric patient, someone that weighs 500 or 600 lbs., say, will lose or gain up to 50 lbs. of weight in a single day. And most of that is water weight. Because, you know, the average person … will go up or down about 5 lbs. in a day," says Irvine. "These people have that problem just magnified on a much larger level. One of the things that the provider needs to take into consideration is if I have a patient that's 550 lbs., maybe that 600-lb. product might not be enough because that patient could easily fluctuate over 600."

If a client is on a weight-loss program or has had weight-loss surgery, such as laparoscopic gastric bypass, weight fluctuation greatly affects what is needed in terms of a bed or support surface. Dr. Vernon explains that different modalities of weight loss can cause patients to lose 100 or more pounds over time. "There comes a time when they don't weigh 400 pounds, they weigh 200," she says. "Then they're kind of down in the range where most of the beds that are offered today will be functional for them. They might not have to have a special surface."

Even with weight-loss surgery, weight change is not immediate. "When you get to be 400 lbs., it takes you a while, no matter how you do it, to not be 400 lbs. It isn't a Star Trek experience where you go in and kind of get that beamed off of you," asserts Dr. Vernon.

Dealers must also consider the lifestyle of the bariatric client, many of which are bed bound. Aside from weight-loss surgery, bariatric clients may undergo additional surgeries to target obesity-related conditions. An example of this type of surgery is a panniculectomy, in which part of the abdominal wall is removed because of infection.

"The trouble with that surgery is that it hardly ever heals initially, so there's this big open wound between the folds of skin," says Dr. Vernon. "So oftentimes, they have to be in bed. And, of course, there are a myriad of issues, like developing deep vein thrombosis and bed sores on the other side of you since you're trying to protect the front side, and it just kind of goes on and on and on. So sometimes they're in bed for two or three months."

Even if surgery is not a factor, the weight of a person causes other problems, such as trouble breathing, that may force the person to remain in bed.

"Many of them are immobile," says Dr. Huffman, who has 20 years experience in the bariatric field and currently helps hospitals develop bariatric surgical programs, "so they're on the bed most of the day. So, they start developing decubitus ulcers." For that reason, many bariatric clients need pressure-relieving mattresses to prevent or treat pressure sores.

Beds "have to not only support weight but they have to have longevity built in there," says Resnick. "If somebody's weighing 600 lbs., he's not getting in and out of bed on a daily basis." In fact, the person "might be bed bound because how do you get somebody who's that big out of bed?"

Another bariatric concern is increased moisture due to excessive perspiration, which ties into the lifestyle of the patient. "Anybody who does not move, the potential for perspiration is highly likely," says Resnick. And increased moisture, whether from perspiration or incontinence, makes pressure sore formation more likely.

Beds & Surfaces for Every Need

Fitting a bariatric client with the appropriate bed and support surface requires attention to the total care of the person. HME providers must consider co-morbidities, the weight of the individual, post-surgical needs and moisture prevention. In addition, caregiver safety is also an issue, so a means to safely rotate or move a bariatric client is essential.

I think it's vitally important that the home medical equipment distributors get out and educate, not only patients, but educate the physicians. Get out there and let them know that there are products available for patients that weigh over 300, 400, 500 pounds. —Dr. Kevin Huffman, American Bariatric Consultants.

Some other important features of bariatric beds and support surfaces include the following.

  • Dimension — "A 1,000-lb. patient can't fit into a 42-inch bed," says Resnick. "They can fit into a 48-inch, but you'd almost have to go to a full or a queen." A standard hospital bed is 36 inches wide, but bariatric beds range from 42 to 60 inches wide.
    Dr. Huffman says safety is key. "It should be wide enough to hold the client safely, so there's no chance of them falling off one side or another."
    Simply put, a standard bed width won't cut it. Wider is better.
  • Pressure relief — As with standard support surfaces, bariatric clients can choose from several pressure-relieving mattresses. The difference is that these mattresses are stronger to support the specific weight of bariatric patients. Invacare's Irvine explains that support surfaces fall into two groups. The first group, designed to prevent pressure sores, includes gel-filled overlays, alternating pressure pads and high-end foam mattresses. The second group, often called therapeutic support surfaces, features products designed to prevent and treat pressure sores. These surfaces incorporate some sort of a pump system that attaches by hose to an air mattress. Alternating pressure, low air loss and turning or lateral rotation mattresses fit into this category.
    Irvine says a low air loss mattress helps to wick away moisture from the skin. "Constant flow of air between the cells in your body keeps you dryer because moisture buildup also contributes to pressure ulcers," he says. "You can kind of think of an air hockey table although you're not fully supported on a cushion of air — that would be the ideal."
    For clients undergoing post-surgical recovery or those who have a pressure sore already, turning mattresses help to stimulate healing. The reason is that "it promotes more blood flow," says Irvine. "It keeps the blood flow from pooling all in one area of your body. It's also useful for a nursing staff, and especially with a bariatric patient, if the patient has a wound say on their hip or on their back, it's very difficult for the nursing staff to turn that patient over on their side and work on the wound, cleaning it out, debride it, whatever they're going to do. Whereas, with a turning mattress, you can just set it to a left turn, hold it there, and the patient is pretty much 90 percent of the way there already as far as turning them on their side. You can work on whatever you want to and then turn them back using the mattress."
  • Electric devices — Though electric devices that raise or lower the bed, or even devices that control the air pressure in certain support surfaces, are essentially the same as standard electric devices, they must be stronger for bariatrics. In fact, many upgraded mattress systems employ two motors to increase power.
    The ability to raise and lower the bed helps post-operative patients get in and out of the bed. After surgery, a client usually needs help sitting up, says Irvine. "Having a bed that raises and lowers generally helps you get in and out of bed because you can adjust the bed height when you're getting out so that your feet are exactly on the floor, and then basically raise the bed up a little bit and use it as an assist to standing up," he says.
    Raising segments of a bed can also aid respiration. Raising the head can help clients with sleeping problems, says Dr. Huffman, because "they have so much weight up against their diaphragm, they don't breathe well to begin with. So, I like to have the head of the bed elevated."

CMS Proposes Change in Bariatric Surgery Coverage

What Providers Need to Know

With the continued rise of obesity rates, it's no surprise that more people will require bariatric services and products, but what does that mean for HMEs?

Resnick asserts that dealing in bariatric products is a specialized business venture. Dealers can't just stock a bariatric bed and call themselves a bariatric dealer. It takes a lot of work forging relationships, learning the products and managing the complete care of the client.

Did You Know? Some bariatric people are too heavy or large to fit into a standard bed, so many end up sleeping on a mattress on the floor. While this is not true for all individuals, says Mike Irvine, product manager of beds and support surfaces at Invacare, Elyria, Ohio, it is commonly reported. Getting bariatric clients off the floor and into a bed makes it easier for them to get up, increases comfort, especially if the bed has the ability to raise or lower the head and feet, and restores dignity.

"For a dealer contemplating going into the bariatric market," says Resnick, "they have to … recognize that they have to inventory and that it's a costly investment. The product will aggressively need to be managed and modified."

That means a bariatric dealer must stock 1,000-lb. beds, says Resnick, or have access to that size product pretty rapidly. In addition, increased costs may include specialized equipment to unload and set up bariatric beds because those products are very heavy. For example, a dealer may require an electric dock to lower the bed up and down.

Possibly the most important aspect of running a successful bariatric business is establishing a referral system with bariatric physicians and surgeons. For that to work, dealers and manufacturers really have to be aggressive to educate the doctors dealing with bariatrics on what products are out there, says Resnick.

"In our industry, we have to educate the referral sources on what's out there," he says, "because they know how to heal a patient and medically treat that patient but they're not really experts on the products that are out there."

Dr. Huffman agrees. The problem with the morbidly obese patient population," he says, "is that most of us in the medical community don't understand what their needs are. We need to be educated." Unfortunately, the medical training programs are not providing enough training, so Dr. Huffman encourages home care providers to educate the community, especially doctors and surgeons, on what products are available.

"A lot of the medical conditions previously, it was the industry that educated us," he says. "A lot of us learned about sleep disorders and sleep apnea through companies who developed diagnostic equipment and treatment equipment. It wasn't necessarily the medical community who educated us; it was those who could supply the product and services. So, I think it's vitally important that the home medical equipment distributors get out and educate, not only patients, but educate the physicians. Get out there and let them know that there are products available for patients that weigh over 300, 400, 500 pounds and that they're specifically designed for those kinds of patients. I would highly recommend those dealers to contact their local hospitals and find out who offers a bariatric surgical program and then go in and offer free in-service."

Even if a physician is busy, Dr. Huffman says providers should meet with staff because many times it's the staff that will recommend equipment to patients.

On the flip side, says Resnick, manufacturers also have to step up to educate dealers, especially those who do not specialize in bariatrics. "If they're planning to get into the bariatric business, they need to confer with manufacturers who will give them an honest education, not a marketing pitch."

Irvine recommends that dealers work with all of the people involved in the management of care for the client, including physicians, nurses, family members and caregivers.

As the market grows and as technology changes, the products available also change. "The amount of pressure-relieving surfaces that are available now clinically has … easily doubled over the last five or 10 years," says Dr. Vernon. "So, I anticipate that there will be further improvements. … As our surgical techniques and treatments change, then sometimes our surface needs change."

For example, the laparoscope has greatly impacted skin wounds by lessening the chance of infection, says Dr. Vernon. Laparoscopes actually make smaller wounds than other surgical procedures, though the technology is not a complete panacea, she says.

"Most of the products out there, they're getting better every day because there's pressure upon other manufactures to step up to the plate and make products that work and not just fit a size," says Resnick.

As with other DME, matching the right product with the right client is essential for good business. To do that, a dealer must know the client's medical history, how medical issues are being managed and who is managing the issues. In addition, providers must take into consideration the other devices needed for co-morbidities.

"Generally these people need … a lot of post-surgical help getting around," says Irvine. "Maybe they need a commode, maybe they need a walker, maybe they need some canes because you want to get them up and you want to get them active. … And so, for the HME dealer, he/she needs to look at this as what does this person need from a complete package standpoint and how can I best offer that."

If the client has diabetes, for example, address the need for a blood glucose monitor. If the client has sleep apnea, a CPAP may be needed, explains Irvine.

"It's all about the patient, and that's what a dealer really has to focus on," says Resnick. "What is the best product that I can put out for that patient? Is it for comfort? Is it for pressure relief? Is it a therapeutic mattress? … You've got to take into consideration that patient, all the time."

Bottom line: When all the bedding needs of a bariatric client are met, comfort follows.

Check out Bariatric Beds & Support Surfaces.

CMS Proposes Change in Bariatric Surgery Coverage

On Nov. 23, 2005, the Centers for Medicare & Medicaid Services (CMS) announced a proposal to modify Medicare coverage of bariatric surgery. The proposal would provide national coverage for Medicare beneficiaries under age 65 for open and laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding under certain clinical circumstances and when performed by a facility meeting evidence-based standards.

Currently Section 100.1 of the National Coverage Determination (NCD) Manual states gastric bypass surgery is covered only in cases of extreme obesity if it is medically appropriate for the individual to have such surgery and if the surgery is to correct an illness that either caused the obesity or was aggravated by the obesity. Intestinal Bypass Surgery (NCD Manual Section 100.8) and Gastric Balloon for Treatment of Obesity (NCD Manual Section 100.11) are not covered by Medicare.

The new policy would exclude coverage for beneficiaries older than age 65, says CMS, because recent studies indicate that bariatric surgery poses significant risks for this age group.

"This proposed limited coverage for bariatric surgery is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives for its beneficiaries, using the best and latest evidence," says CMS Administrator Mark B. McClellan, M.D., Ph.D.

While diet and exercise are the mainstay of treatment, says McClellan, bariatric surgery may be a helpful treatment option for people with extreme obesity whose treatments have been unsuccessful and who have developed health problems as a result of obesity.

CMS is also proposing facility criteria that includes a credentialing program for surgeons, a review of staff and consultant qualifications, an integrated program for patient care, written procedures for patient consent and adverse event reporting, and appropriate equipment for patient care.

After CMS reviewes public comment, a final decision memorandum from CMS is anticipated in the first quarter of 2006.

Bariatric Beds & Support Surfaces

Bariatric Bed

Designed with a low position of only 8 inches, the Low Bed 800 from Big Boyz electrically adjusts to multiple positions and accommodates 800 lbs.

Mattress System

The Power-Pro Elite® Mattress System from Blue Chip Medical Products, which supports up to 1,000 lbs., combines true low air loss and alternating pressure therapies all in one portable system.

Bariatric Bed

Available with tilt-in-space, the ExpandaCare bed from Camtec adjusts from 37 to 54 inches in less than one minute.

Bariatric Bed

Gendron's EC + Extra-Care? Bariatric Beds are constructed with a rugged frame that is engineered to provide maximum stability for up to 1,000 lbs. as well as a 60-degree angle elevated backrest.

Bariatric Bed

The bed frame on the Invacare 1,000-lb. Bariatric Bed extends to the edges of the bed deck for better support, while a hand pendant positions the head and foot sections and bed height.

Bariatric Bed

The 800-lb. capacity Ultima 80 from Leisure-Lift Inc. features a Cardio Chair for improved respiratory and circulatory functions.

Mattress System

The Stage IV® Millennium 3 mattress replacement system from SenTech Medical Systems helps skin wounds heal with options of alternating pressure, low air loss and air flotation.

This article originally appeared in the February 2006 issue of HME Business.

The Key to Patient Engagement